Audience

This policy brief is for policy makers, program managers, researchers, and other professionals dealing with nutrition, health, community development, and social and behaviour change and those with an interest in maternal and child health and development in County.

Purpose

There is increasing recognition of the need for implementation research that is designed to provide context-specific information and data to inform decisions for planning nutrition and public health interventions. This brief provides evidence for decisions to improve maternal and young child nutrition derived from a systematic landscape analysis in the county.

1. Introduction

: This policy brief summarises key results from conducted in selected communities in the four a study designed to identify potential inter- divisions of Kitui Central (Tiva), Lower Yatta ventions to improve nutrition in infants and (Kalunini), (Mwamba), and young children in , . The (Musengo). study was commissioned to provide information necessary for the design of Two research approaches were used in Kitui appropriate high-impact nutrition County:

interventions in Kitui to improve nutritional Gretel Pelto and Faith Thuita Faith and Pelto Gretel KenyaBrief Policy outcomes at the household level. • Ethnographic research was conducted using the GAIN-initiated Focused The climate of Kitui County varies between Ethnographic Study of Infant and arid and semi-arid, with very erratic and Young Child Feeding Practices (Pelto unreliable rainfall. Most of the area is hot and Infants and Young Children in Kitui County in andKitui Children Young Infants and Armar-Klemesu 2014). dry. The limited availability of water, coupled with poor soil fertility, presents major challenges for crop cultivation. More than a • A dietary assessment and an applica- third of the county’s residents reside in the tion of Optifood, a linear programming Feeding marginal mixed farming regions, which rely software tool largely on livestock for food (milk and other products) and revenue. However, the liveli- An FES applies well-established ethnographic hood system is beset by high vulnerability to methods to obtain data from caregivers on recurrent and prolonged droughts, lack of determinants of dietary practices, including water and pasture, high livestock mortality, social, economic, cultural, technological, and and repeated crop failures. The low-lying environmental factors (Pelto et al. 2012). This eastern and central areas of the county are research approach uses sampling procedures also prone to flooding. The study was that ensure representation of economic strata

This brief is made possible by the generous support of the American people through the U.S. Agency for International Development (USAID). The contents are the responsibility of GAIN and do not necessarily reflect the views of USAID or the United States Government. 1

and age sub-groups of infants and young use practices for infants and young children, children 6–24 months of age. Optifood is a and associated constraints (Ferguson et al. research tool that uses data obtained from 2006). These two approaches combined are dietary intake measurement to reveal the used to identify context-specific opportunities strengths and weaknesses of current diets. It and limitations for dietary improvement identifies locally appropriate food-based through behaviour change interventions (Hotz modifications to improve dietary adequacy, et al. 2015). taking into account local dietary norms, food

2. Overview of the Situation: The Importance of

Nutrition in Infancy and Early Childhood

Adequate nutrition is essential to growth, complementary feeding from 6 months health, and development during infancy and through at least 2 years, and continued early childhood. Under-nutrition, which in breastfeeding to 2 years of age or beyond. addition to being the result of inadequate Appropriate complementary feeding includes diets, is also influenced by hygienic practices, timely initiation of solid/ semi-solid foods health provision, and care, is an underlying from 6 months of age; increasing the amount, factor in 45% of child deaths (Black et al. density, and variety of foods; increasing the

2013). The immediate consequences of poor frequency of feeding as the child gets older;

: nutrition during the early formative years responsively feeding the child; and ensuring include significant morbidity, mortality, and that good hygiene practices are used in delayed mental and motor development. In preparation and feeding, while maintaining the long term, early nutritional deficits are breastfeeding. linked to impairment in intellectual performance, decreased work capacity, and IYCF practices in Kenya are currently less poorer reproductive outcomes and overall than optimal. Only 25% of young children are health during adolescence and adulthood. The fed adequately diverse diets (Kothari and ‘1,000-day window’—the period from Abderrahim 2010). In previous research, care-

Gretel Pelto and Faith Thuita Faith and Pelto Gretel givers, families, and communities in Kenya KenyaBrief Policy conception to a child’s second birthday—is a critical time frame for the promotion of have been reported to lack up-to-date knowl- optimal growth, health, and behavioural edge of optimal IYCF practices, particularly development (World Health Organisation during the complementary feeding period (Thuita 2008; Nduati et al. 2008; Israel- Infants and Young Children in Kitui County in andKitui Children Young Infants [WHO] 2010). Ballard et al. 2009). Improving IYCF practices are a major determinant of complementary feeding practices amongst child nutritional status outcomes. Optimal Kenyan children aged 6–23 months could IYCF practices include exclusive breastfeed- significantly contribute to improved child Feeding ing for the first 6 months and appropriate survival, health, and development.

3. Overview of Methods To assess current practices and identify poten- interviews. The modules are designed to tial interventions to improve nutrition in explore a range of issues, including foods for infants and young children, researchers used infants and young children, food preparation the FES manual and protocols (Pelto and and feeding practices, sources of food Armar-Klemesu 2014). Each protocol acquisition and food expenditures, types of consists of a set of modules, which are problems faced by parents of infants and administered through in-depth one-on-one young children, food and nutrition problems

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of infants and young children, perceptions probing to expand and interpret the initial about health and food, and perceptions about responses. The nutritional assessment of IYC micronutrient supplements and fortification of diets was done via a cross-sectional dietary infant foods. The modules’ open-ended survey and analysis using Optifood software questions were administered with extensive (Ferguson et al. 2015).

4. Results Infant and young child diets estimated breastmilk intakes (Ferguson et al. 2015). In Kitui, breastfeeding rates from 6-23 months are high. All mothers reported that the Increased frequency of feeding specific, index child was initially breastfed and all but locally available foods could go a long way in 2 of the 32 children aged 6–23 months were filling nutrient gaps in the IYC diet. This breastfed at the time of the study. However, includes consumption of animal milk three analysis of the current diets of infants and times a day every day (added to porridges so young children showed that they are as not to encourage displacement of breast inadequate in many nutrients. milk); green leafy vegetables, millet, and a fortified cereal once a day every day; legumes The majority of children consumed porridges one or two times a day every day; and meat, (based primarily on unrefined maize flour and

fish, or eggs three times per week.

: secondarily on the preferred grains, i.e. millet and sorghum). The most common accompani- While incorporating these changes into ment to these staples was the broth from current diets would allow infants and young vegetable stews. Milk, as a separate beverage, children to meet their requirements for nine was consumed by many children, but tended nutrients (6–11 months) or seven nutrients to decrease in the second year of life. Few (12–23 months), after accounting for children consumed animal flesh foods (0%– estimated breastmilk intakes, adequate intakes 2%) or fresh fruits (8%–9%). of iron, zinc, and calcium would be difficult to achieve, and additional solutions are

Gretel Pelto and Faith Thuita Faith and Pelto Gretel The limited number of foods commonly KenyaBrief Policy required to increase access to good food consumed by children in Kitui was reflected sources of these nutrients beyond current food in low dietary diversity scores, which is a use and dietary patterns (Ferguson et al. general measure of the quality of the diet. 2015).

Fewer than 25% of children achieved the Infants and Young Children in Kitui County in andKitui Children Young Infants minimum dietary diversity of 4 food groups Food acquisition for infants and or more for children 6-23 months of age young children (WHO 2008). The nutrient density in the infant and young child (IYC) diet, another The results indicate that not only do Feeding measure of dietary quality, was often low. caregivers generally access foods through The nutrient densities of diets of children 6–8 markets, but several food items used months old were below WHO desired levels specifically in IYC diets are obtained for 8 of 10 key nutrients examined (the primarily from markets. None of the families exceptions being vitamin A and vitamin C). in the study produced all of the foods that For the age sub-groups in the 9–23 month they needed to feed themselves and their range, nutrient densities were below desired children. The amount of time that they could levels for 7 of the 10 key nutrients. The most rely on home-produced staple foods varied, serious problem nutrients were iron and zinc but was never more than a few months at in all age groups and vitamin B12 in the 12– best. 23 month age group, after accounting for

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The preferred grain for infant porridge is because women have no choice. Githeri (the millet, which is almost always made from a mixture of whole maize and beans that is a commercial source, either a branded product family food staple) is regarded as particularly or a generic flour. Other commercially bad because it is difficult for children to produced, multi-grain porridges are also given chew. A few caregivers spontaneously to infants and young children. When millet suggested that soda and commercial, porridge is not available, maize flour porridge reconstituted juices are also not good. is given. The maize flour may be purchased or comes from milling home-produced maize There are major gaps between what or purchased maize. caregivers want to feed their infants and young children and what they are able to give Caregivers’ nutrition knowledge them. Mothers would like to feed cereals that

they regard as nutritious. Much of the time One important finding is that caregivers they are forced by lack of resources to feed generally have sound nutrition knowledge plain maize porridge, a food that they have about feeding infants and young children. been taught is nutritionally inferior.. Even the They have acquired this from many sources: addition of milk is not seen as raising the school, medical professionals at health ‘healthiness’ value of maize porridge to that clinics, and community health workers. Most of millet porridge. Millet, on the other hand, importantly caregivers are aware of and is viewed as a food of high intrinsic strongly committed to the idea that what

nutritional value.

: children eat affects their growth and their health. Their knowledge accords well with Hygiene and food safety contemporary thinking about IYCF. Another important positive finding from the ‘As far as I am concerned, giving quality study is that caregivers have well-developed food is all that is needed to keep a child ideas about food hygiene and the importance healthy. If a mother gives quality food, the of protecting food from contaminants. They child will grow well and when taken to the are aware of and concerned about personal hospital for weighing, the nurses will tell you that the child is growing well’. hygiene, food hygiene, and food safety. They

Gretel Pelto and Faith Thuita Faith and Pelto Gretel attempt to give their children both nutritious KenyaBrief Policy A small minority of the randomly selected and safe food. However, their preparation and respondents were highly knowledgeable; the storage practices may still put children at risk quotation below was elicited in response to an of food-borne diseases because they do not

interviewer’s question about whether the have sufficient and consistent access to the Infants and Young Children in Kitui County in andKitui Children Young Infants caregiver had ever heard of vitamins: technology that helps ensure food safety.

‘There are different types of vitamins—A, Caregivers prepare food over wood fires that C, D—which help prevent the baby from require substantial efforts, both to acquire illness. If the baby is safe from infection, Feeding she will generally be healthy, and I will feel firewood from the surrounding countryside good. In my view, the type of diet the and to build and maintain the fire. baby eats will make the baby strong’. Consequently, they cannot easily prepare or reheat food for their children on a schedule to For the most part, cultural beliefs are not meet children’s needs, which means that preventing caregivers in Kitui from using prepared foods have to be stored for many affordable nutritious foods that are available hours without benefit of refrigeration that in their environments. However, fish is not would prevent growth of pathogens. seen as a desirable food for anyone and is not given to infants and young children. ‘I cook multiple portions because I have a Traditional foods are widely regarded as thermos flask to store the porridge. The inadequate nutritionally and are given only thermos flask keeps the porridge hot.

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When the baby wants to feed, all I do is ‘All the harvest is finished, so we have to just give it to her. The flask is placed on buy all the food. During these months the kitchen table, a raised surface to keep water is also a problem. The rock catch- from breakage or from anything else’. ment gets its water from the rains. It dries up during these months and we have to ‘I always make multiple portions because I travel for about 2 hours to get water from have no time to prepare it when the child the traditional wells’. needs to feed. Besides, I am leaving him with neighbours, thus I have to leave food ‘The water situation is so bad that for him’. sometimes people do not eat because there is inadequate water. Though food While the picture with respect to caregiver may be available in the household, there is knowledge and practice is generally favour- completely no water to cook the food. We able, there were two areas of weakness that are forced to go look for water very far. emerged from the study: Sometimes we fail to find water and people are forced to sleep hungry’. • The use of black, sugar-sweetened tea, often served without milk, is a frequent Technology and infrastructure solutions are dietary component. Caregivers prepare required to relieve these additional, this in the morning and store it in underlying stresses working against adequate thermos bottles or other containers, so child nutrition both indirectly, through that it is handy to feed during the day, mothers’ time constraints, and directly,

in response to child thirst. It is also left through the ability to cook food.

: to be fed by alternate caregivers when mothers are away. Food insecurity • Food is commonly stored under unsafe Food insecurity is a widespread concern and conditions after its initial preparation. common and escalating problem for care- givers in Kitui throughout the year, not just For both of these findings, the results indicate during the dry season. The majority of potential problems, but they do not provide caregivers brought up this issue when asked definitive evidence of adverse effects on IYC what challenges they face in raising their

nutrition and health. Further studies are children. It was often the first problem they Gretel Pelto and Faith Thuita Faith and Pelto Gretel KenyaBrief Policy required to confirm this. discussed. Because no households can meet their food needs from home production, food The dual problems of fuel and water insecurity is often expressed as ‘a lack of Collecting firewood and fetching water are money to buy food’, as well as a lack of food Infants and Young Children in Kitui County in andKitui Children Young Infants major time- and energy-consuming household from their own production. management tasks for women in Kitui. These Although many families face food insecurity two fundamentally important responsibilities throughout the year, the problem is more compete for time to engage in other, equally severe in some months than in others. During

Feeding essential activities in agricultural production; periods of food insecurity, caregivers adapt income-earning activities; and child care, their recipes. They make simple dishes including feeding and food acquisition and without the additions that add flavour and preparation. nutrients. Caregivers described preparing The competition for women’s scarce time is foods for their infants and young children particularly acute in the dry season when without oil, sugar, and milk. This leads to there is a heavy need for them to engage in problems in children’s acceptance of food and income-earning activities to purchase food. It to the loss of nutritional qualities in their diet. is further exacerbated by the scarcity of water, Caregivers described efforts to buffer their which is critically important because it children from food insecurity by skipping directly affects IYC nutrition. meals themselves and eating less. But these

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compensatory moves are not sufficient to other social programs, borrowing food and/or prevent nutritional and behavioural problems money from relatives, and buying food on in their children. credit at local stores. The range of options open to individual women varied widely. For The ability of households to cope with food example, between and even within commu- shortages is dependent on many factors. Some nities, access to social programs appears to be of these factors are related to differences in highly variable. In addition, help from rela- household agricultural management and con- tives is not an option for many, and access to ditions, including the amount of staple foods credit depends on the willingness of grown for home consumption; in availability individual shopkeepers to offer such an and types of household plots to extend the accommodation. growing season; and in the feasibility of

growing a diversity of crops to expand the Emotionally, periods of serious food shortage range of food available during the good are very difficult. The following quotations months and fill in gaps during the worst provide some indication of the stress caused months. Other factors are related to social and by food insecurity in Kitui: demographic conditions, including the number of adults who contribute financially ‘My head aches because of thinking a lot. I keep worrying because I do not have food to the household, the size of the household and I do not know where to seek help. I and the number of children, and health think, yet I do not know what to do.

conditions of the household’s adults. Single Sometimes the head aches and the body

: mothers have the most difficult time coping feels weak and sick’. with food insecurity, and their children are at ‘It’s very painful not to be able to feed greatest risk of malnutrition. your children. Sometimes I sit down and cry because I look at unhappy children Caregivers use a variety of resources to try to sitting around me yet I can’t give them meet the challenge of not enough food and the anything. Children do not have school lack of money to buy food. Some caregivers fees and even more there is no food. I feel have more resources than others. Caregivers sad. It’s very painful not be able to feed

who are raising their children alone—because your children’. Gretel Pelto and Faith Thuita Faith and Pelto Gretel KenyaBrief Policy their partners are not in the community or ‘Though my husband helps out, have died or because they have no close sometimes when I ask him for money to relatives nearby—are the most severely buy food he says he does not have it … affected by food insecurity. You know I have children; I cannot run

away and go back to my family home. I Infants and Young Children in Kitui County in andKitui Children Young Infants The activities and strategies that caregivers know well that going back to our home reported using to obtain food, or money to won’t help. Who will provide for my children? When the situation becomes buy food, included jobs for others in the com- worse, I cannot ask for help from my

munity to earn small amounts of money, father, he also has his own problems … Feeding making craft products to sell, short-term Some days we sleep hungry; other times entrepreneurial activities, food-for-work and we find something to eat. That is life for us’.

5. Summary and Conclusions Caregivers appreciate the health value of the culturally acceptable as foods for infants and nutritious foods in their local food system and young children do not provide an adequate use them to the extent that their limited basis for healthy IYC growth and develop- resources permit. However, the foods that ment. Although dietary adequacy can be caregivers have access to and that are improved using behavioural change inter-

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ventions, they alone are insufficient; addi- Increasing the market accessibility of nutri- tional interventions are needed to facilitate tious foods is one part of the equation for access to nutritionally adequate diets for all filling nutrient gaps. Caregivers are heavily infants and young children. oriented to purchasing healthy foods for infants and young children from the market. Caregivers appreciate the importance of good But markets must be financially accessible to hygiene and food safety, but are constrained households, and improving caregivers’ by inadequate access to water; the difficulty income stream is therefore essential to realise of obtaining and cooking with firewood, their benefits from market-dependent interventions. only fuel; and the lack of refrigeration. They prepare special foods for their infants and young children once a day and are not able to

prepare fresh food over the course of a day. Recommendations These technological constraints, together with In this section, we make suggestions for two the demands of farm work and hours spent types of interventions, ‘nutrition-sensitive working to earn money, contribute heavily to interventions’ and ‘nutrition-specific’. severe pressures on caregivers’ time, Nutrition-sensitive interventions refer to a including time for taking care of and class of development activities, for example interacting with their infants and young in agriculture, safety nets, early child children. The lack of good child care options development and schooling, that affects

when women must be away from their nutritional status and well-being because they

: children is a source of worry for mothers and address the underlying causes of a serious problem for optimal child health. undernutrition, while nutrition-specific interventions are those that address the In sum, the results show that a number of immediate determinants nutrition (Ruel et al. different factors are responsible for poor 2013). nutrition in infants and children, and it is not possible to identify one that is most important. Nutrition-sensitive interventions related

to technology and environment actions Gretel Pelto and Faith Thuita Faith and Pelto Gretel

KenyaBrief Policy Implications for intervention actions • Improve access to clean water sources. The implication of the finding that multiple • Promote the use of improved stoves to factors are responsible for under-nutrition can use firewood more efficiently. be viewed as either a discouraging or a Infants and Young Children in Kitui County in andKitui Children Young Infants positive outcome. It is discouraging because it • Introduce stoves that use alternatives to shows that there is no one simple solution, firewood. comparable to giving an antibiotic to cure an • Develop better methods for safer food infection. But the positive outcome is that storage.

Feeding many different actions can be taken, each of which will contribute to improving the High-priority interventions in agriculture nutrition of infants and young children in • Identify the reasons for the reported Kitui. Some of these actions are ‘nutrition- problems in household millet specific’ and some of them are ‘nutrition- production and improve capacity to sensitive’ (defined below). The potential grow millet. actions vary in the time frame needed to • Improve local milk production, at both implement them and the resources that are the household and community levels. required, and in the time it will take to show results. They also vary in the policies that are • Explore the potential to improve access required to initiate and support them. to green leafy vegetables through

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homestead and community gardens. children is seriously negatively Innovative, low-technology strategies affected by maternal depression and the may be required to overcome the arid results of the study suggest this is a conditions in the area. common problem. • Develop alternative, affordable, short- Interventions to improve household term care facilities for infants and food security by shoring up household young children so that women can economic status engage in domestic and income- • Create new income-earning opportu- earning activities without endangering nities for women though non-farm their own and their children’s health. activities. In Kitui, with its strong tradi-

tion of crafts, developing opportunities for women to engage in work craft Nutrition-specific interventions production and ensuring a fair return • Introduce micronutrient powders and on their labour holds promise as a other special nutritional formulations to means of improving household income. help fill the nutrient gaps in local diets. Other forms of small-scale manufactur- • Promote the use of foods that are ing could also be explored. (Such currently seen as ‘additions’ to IYC development efforts must be diets and identify ways to extend this implemented in a fashion that protects

practice to incorporate other nutrient-

: breastfeeding and ensures that infants dense ingredients into IYC dishes (e.g. and young children are not left in the millet, green leafy vegetables in care of inappropriate caregivers.) addition to just vegetable broth, milk, • Develop and expand programs to bean flour). Make sure that these identify and provide financial support nutrient-dense ‘food additions’ are to women and households in Kitui who available in times of food scarcity, are at risk during periods of financial when children are particularly hardship. vulnerable.

• Contextualise existing behaviour Gretel Pelto and Faith Thuita Faith and Pelto Gretel

KenyaBrief Policy Interventions to improve household capacity to provide quality care for change communication and nutrition infants and young children education messages used in community and public health nutrition activities to • Develop services and programs to address the specific, realistic dietary Infants and Young Children in Kitui County in andKitui Children Young Infants address psychological stress in women, changes that have been identified and particularly depression, because there that can be made within current is growing evidence that health and constraints.

development of infants and young Feeding

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6. References Black R.E. et al. 2013. ‘Maternal and child undernutrition and overweight in low-income and middle-income countries’. The Lancet 382, 427–451.

Ferguson E. et al. 2006. ‘Design of optimal food-based complementary feeding recommendations and identification of key “problem nutrients” using goal programming’. Journal of Nutrition 136, 2399–2404.

Ferguson E. et al. 2015. ‘Zinc, iron, and calcium are major limiting nutrients in the complementary diets of rural Kenyan children’. Maternal & Child Nutrition 11(Suppl. 3), 6- 20.

Hotz C. et al. 2015. ‘Constraints and opportunities for implementing nutrition-specific, agricultural and market-based approaches to improve nutrient intake adequacy among infants and young children in two regions of rural Kenya’. Maternal & Child Nutrition 11(Suppl. 3), 39-54.

Israel-Ballard K., Waithaka M., and Greiner T. 2009. Kenya Infant Feeding Assessment: Eastern and Western Provinces. Washington, DC: PATH.

Kothari M. and Abderrahim N. 2010. Nutrition Update 2010. Calverton, MD: ICF Macro.

Nduati R., Arum S., and Kageha E. 2008. Beliefs and attitudes around infant and young child

: feeding in Kenya: findings from a rapid qualitative assessment. , Kenya: PATH.

Pelto G.H., Armar‐Klemesu M., Siekmann J., and Schofield D. 2012. ‘The focused ethnographic study “assessing the behavioral and local market environment for improving the diets of infants and young children 6 to 23 months old” and its use in three countries’. Maternal & Child Nutrition 9(S1), 35–46.

Pelto G.H. and Armar-Klemesu, M. 2014. ‘Focused Ethnographic Study of Infant and Young Child Feeding 6–23 Months: Behaviors, Beliefs, Contexts and Environments’. Available at:

http://www.hftag.org/resource/1-fes-manual-v1-feb-2014-pdf/. Gretel Pelto and Faith Thuita Faith and Pelto Gretel KenyaBrief Policy Ruel, M.T., Alderman, H., and Maternal and Child Nutrition Study Group. 2013. Nutrition- sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? The Lancet 382, 536-551.

Thuita F.M. 2008. Infant and young child feeding practices in Kenya: A review of the literature. Infants and Young Children in Kitui County in andKitui Children Young Infants Nairobi, Kenya: PATH.

WHO, 2008. Indicators for Assessing Infant and Young Child Feeding Practices. Part 1 Definitions. Geneva: WHO.

Feeding WHO. 2010. Indicators for Assessing Infant and Young Child Feeding Practices. Part 2 Measurement. Geneva: WHO.

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This policy brief was prepared by Gretel Pelto (Cornell University) and Faith Thuita (, School of Public Health). It is based on studies written by Gretel Pelto and Margaret Armar-Klemesu (Feeding Infants and Young Children in Kitui County, Eastern Kenya: Report to GAIN on the results of a Focused Ethnographic Study. GAIN Background Report; May 2013), and a report written by Elaine Ferguson, Christine Hotz, and Doris Wiesmann (Enhancement of nutritional content of complementary foods through agricultural interventions in Kitui, , Kenya: Report to GAIN on the results of the gap analysis done in Kitui. GAIN Background Report. April 2013), with field research by Judith

Kimiywe and Peter Chege ().

:

Gretel Pelto and Faith Thuita Faith and Pelto Gretel

KenyaBrief Policy

Infants and Young Children in Kitui County in andKitui Children Young Infants Feeding

For more information, contact: Adan Kabelo, GAIN Kenya Country Director [email protected]

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